1Perera N, Agboola S. BMJ Global Health 2019;4:e001415. doi:10.1136/bmjgh-2019-001415

Are formal self- care interventions for healthy people effective? A systematic review of the evidence

Nilushka Perera,1 Shade Agboola2

Research

To cite: Perera N, Agboola S. Are formal self- care interventions for healthy people effective? A systematic review of the evidence. BMJ Global Health 2019;4:e001415. doi:10.1136/bmjgh-2019-001415

Handling editor Seye Abimbola

Received 14 January 2019Revised 8 April 2019Accepted 13 April 2019

1Evaluation, Impact and Policy, Best Beginnings, Battaramulla, Sri Lanka2Public Health, Nottingham City Council, Nottingham, UK

Correspondence toNilushka Perera; nilushka. p@ gmail. com

© Author(s) (or their employer(s)) 2019. Re- use permitted under CC BY- NC. No commercial re- use. See rights and permissions. Published by BMJ.

Key questions

What is already known? ► Health- promotive self- care is a growing area of health promotion that shows significant promise in outcomes and reduced expenditure but there is much less attention given to health- promotive self- care interventions for healthy populations.

What are the new findings? ► Current studies are of low to moderate quality and majority are from high- income countries limiting the strength of the pooled effects.

► There is a clear lack of consistency in the terminolo-gy used in self- care resulting in varying intervention design, restricting the comparability of studies.

What do the new findings imply? ► Develop a globally accepted definition and frame-work for health- promotive self- care and establish clear parameters of its use and definition.

► The need for more robust high- quality evaluation study designs for health- promotive self- care inter-ventions using behaviour change theories and con-sistent follow- up methods to improve data quality.

AbsTrACTIntroduction Preventative interventions are shown to be effective in reducing 40% of the mortality due to unhealthy behaviours and lifestyles. Health- promoting self- care has been recognised as a promising strategy in preventative health. However, self- care research is being done around the self- management of chronic illnesses and the promotion of self- care practices among healthy populations has been overlooked by many healthcare systems.Method The study methodology was a systematic review with a narrative synthesis. The search was done through seven academic databases, reference tracking of selected articles and grey literature. The scoping, selection, screening and quality assessments of the articles were reviewed independently by two reviewers.results Sixteen studies met the inclusion criteria. Self- care behaviour, health- promotive lifestyle changes and medical care utilisation were some of the main outcomes evaluated in the studies. Positive effects were seen in increasing self- care and health- promotive behaviours in most interventions although limited or mixed impact was seen in health attitudes, beliefs and utilisation of medical services. Most studies were from high income settings with low- quality study designs. The complexity of the word ‘self- care’ and inconsistencies in the terminology used in health- promotive self- care were significant highlights of the study.Conclusion Health- promoting preventative self- care interventions show promise in increasing the well- being of healthy people. However, the methodological drawbacks limit the generalisability of the findings. As the demand for self- care interventions increases, the lack of a formal globally accepted definition and framework and complexity of behaviour change are key limitations to consider moving forward.

InTroduCTIonPreventative interventions, using health- promotive strategies, have been shown to be effective in reducing up to 40% of the mortality caused by unhealthy behaviours and lifestyles.1 Health promotion, a core strategy in prevention, emerged in the 1980s creating a novel approach to public health interven-tions and practices.2 Self- care is a form of

health promotion, disease prevention and disease control, which is built on increasing personal commitment and responsibility to one’s health. An overall accepted definition of self- care in health, and one that guided this review, is acquiring the necessary knowledge, skills and attitudes required to achieve and maintain good health.3 In line with the third Sustainable Development Goal of ensuring healthy lives and promoting well- being for all at all ages,4 self- care encourages a change in current public health approaches, and explores the processes involved in accessing primary care. Primordial prevention—that is, the preven-tion of emergent risk factors within a popula-tion—is a key consideration in understanding the relationship between self- care and health promotion.5 This is important in encouraging non- diseased populations to adopt healthier lifestyles and social values. Health- promoting

on August 13, 2020 by guest. P

rotected by copyright.http://gh.bm

j.com/

BM

J Glob H

ealth: first published as 10.1136/bmjgh-2019-001415 on 6 N

ovember 2019. D

ownloaded from

2 Perera N, Agboola S. BMJ Global Health 2019;4:e001415. doi:10.1136/bmjgh-2019-001415

BMJ Global Health

Figure 1 The self- care continuum.7

self- care is one such promising primordial preventative strategy and was the primary focus of this review.5 6

Illness type and an individual’s unique situation deter-mine the type of self- care behaviours they undertake. According to the Self Care Forum in the UK, self- care is a continuum ranging from daily health choices to recovery from a major trauma as illustrated in figure 1.7 Health- promoting self- care behaviours would be classified to the left side of the spectrum which covers daily choices, life-style and self- managed ailments.

In many high- income countries (HIC), general prac-titioners (GP) are increasingly devoting a significant amount of time, dealing with minor illnesses, such as fever, cold, sore throats and ear infections, which are often amenable to self- care interventions using home remedies.8 A rising concern for health systems in coun-tries classified as high income, like the UK, is the increase in non- urgent emergency department attendances, with evidence suggesting that about 40% of emergency care appointments are diagnosed to be self- managed at home.9 When advanced care is sought for minor illnesses, there is an increased financial burden on the healthcare system and an impact on the patient’s well- being as a result of being deprioritised in emergency care,10 highlighting the need for promotive self- care and raising public aware-ness. Importantly, the ideologies towards self- care and the adoption of its practice are influenced by a country’s health system, provision of services, methods of health system financing and social values underlying each system.10

Previously, the main focus of self- care research was on self- management of chronic illnesses. There are now well- known formal programmes, mostly in HICs, designed to provide supported self- management to people with

chronic illnesses such as diabetes, asthma, mental illnesses, osteoarthritis and hypertension, and their effec-tiveness is well established.11 Evidence also shows that gender, age, socioeconomic status (SES), self- efficacy and social relationships are determinants in the acceptance and engagement of health- promotive self- care interven-tions.5 12–14 There is, however, limited evidence on the effectiveness of such interventions for healthy individ-uals. This review, therefore, aimed to explore the overall effectiveness of preventative formal self- care programmes for healthy populations, by describing and documenting existing interventions and systematically assessing their effectiveness.

MeTHodsA systematic review of literature with a narrative synthesis15 was conducted. This approach focuses on explaining and summarising the findings of multiple heterogeneous studies using text and words.15 The research question and its parameters were further refined by applying the Popu-lation, Intervention, Comparator, Outcomes, Context and Study design framework to selected studies.16 This also guided the development of the inclusion and exclu-sion criteria (box 1).

search strategy and study selectionLiterature was identified from: a range of electronic databases (Medline, CINAHAL, EMBASE, PsycINFO, Cochrane Library, Campbell Collaboration, the Cost- Effectiveness Analysis Registry and Google Scholar); reference tracking of selected articles; and grey litera-ture. The literature search included studies from incep-tion to June 2016 which was the time of undertaking

on August 13, 2020 by guest. P

rotected by copyright.http://gh.bm

j.com/

BM

J Glob H

ealth: first published as 10.1136/bmjgh-2019-001415 on 6 N

ovember 2019. D

ownloaded from

Perera N, Agboola S. BMJ Global Health 2019;4:e001415. doi:10.1136/bmjgh-2019-001415 3

BMJ Global Health

box 1 Inclusion and exclusion criteria

Inclusion ► Studies describing a formal programme of supported ‘self- care’ interventions with a preventative focus and encompassing healthy populations.

► Studies with a clinical study design including randomised con-trolled trials (RCT), cohort studies, case–control studies, ecological or cross- sectional studies.

► Studies that evaluated the effectiveness of the self- care interven-tion on health outcomes with a follow- up of more than 3 months.

exclusion ► Any study that had interventions that focused on self- management, self- help, self- monitoring or self- efficacy.

► Non- evaluative studies, commentaries and letters to editors. ► Studies that were not explicitly identified by the authors as focusing on self- care programmes or that did not have self- care as a basis for the intervention.

Table 1 Search terms used

Search terms

Self- care self- care OR self AND care OR self care

Evaluation evaluation studies OR evaluation studies as topic OR evaluation effectiveness AND evaluation studies OR evaluation studies as topic OR evaluation

Illness prevention Illness AND prevention and control OR prevention AND control OR prevention and control OR prevention

Preventative health Preventative AND health OR health

Proactive care Proactive AND care

Health promotion health promotion OR health AND promotion OR health promotion AND programs

Adult adult OR adults OR

Lifestyle interventions life style OR life AND style OR life style OR lifestyle AND interventions

this study. Further articles were identified by reviewing reference lists of all eligible articles. Development of the search strategy started with an initial scoping review on Medline using preliminary search terms that had been agreed on by the review team. Subsequently, three arti-cles that fit the review criteria were used as a template to examine the keywords that it uses to be indexed in databases. A list of these terms (table 1) was then devel-oped and each term entered into PubMed to find its related MeSH terms. Screening of identified literature was guided by the Preferred Reporting Items for System-atic Reviews and Meta- Analyses framework as illustrated in figure 1.17 The three- stage screening process involved title screening, abstract screening and full- text screening.

data synthesis and quality assessment of studiesSelf- care interventions are highly heterogeneous in design and outcomes. Therefore, this review analysed the included articles using only a descriptive and narrative synthesis and a meta- analysis was not conducted. Data analysis was focused on evaluating the different measures of health outcomes that indicated behaviour change, and thus the overall effectiveness of self- care interventions for healthy populations. The methodological quality of selected studies was assessed using the Quality Assess-ment Tool for Quantitative Studies by the Effective Public Health Practice Project.18 The quality assessment of the included studies is shown in table 2. This tool was consid-ered suitable as it was specifically developed to evaluate public health studies and is adapted to accommodate for heterogeneity of interventions.18 All studies in the review were assessed for selection bias, study design, confounders, blinding, withdrawals and dropouts, inter-vention integrity and analyses. The scoping, screening and data extraction stages of the review process were inde-pendently conducted by two reviewers, and all conflicting ideas were discussed until a consensus was reached. This assessment tool18 allows the assessment of each of these sub areas of the study and applies one of the three ratings: strong, moderate or weak, depending on the information provided in the article. A global rating was given for each article where a study is recognised as ‘strong’ if it had no weak ratings, ‘moderate’ if it had one weak rating and ‘weak’ if it had two more weak ratings. The quality assess-ment was carried out independently. The quality assess-ment was also carried out independently by two reviewers and any clarifications discussed.

Patient and public involvementAs this study is a systematic review, this review was conducted without patient involvement. Patients were not invited to comment on the study design and were not consulted to develop patient- relevant outcomes or inter-pret the results. Patients were not invited to contribute to the writing or editing of this document.

resulTsFrom the academic database search, 905 articles were identified (see breakdown in figure 2). Seven additional studies that met the inclusion and exclusion criteria were identified through reference lists. A total of 835 articles were excluded after title and abstract screening and 77 articles were left for the full- text review. A total of 16 arti-cles were included in the final review.

The included studies were published between 1982 and 2008 with 12 studies from the USA. The remaining four studies took place in the Islands of Hawaii,19 Egypt,20 Turkey21 and the UK.22 Based on the assessment, the methodological quality of majority of the studies was rated low with a few studies rated as moderate quality (refer to table 3). The majority of the study designs were randomised controlled trials (RCT),23–26 quasi

on August 13, 2020 by guest. P

rotected by copyright.http://gh.bm

j.com/

BM

J Glob H

ealth: first published as 10.1136/bmjgh-2019-001415 on 6 N

ovember 2019. D

ownloaded from

4 Perera N, Agboola S. BMJ Global Health 2019;4:e001415. doi:10.1136/bmjgh-2019-001415

BMJ Global Health

Tab

le 2

Q

ualit

y as

sess

men

t of

incl

uded

stu

die

s (E

ffect

ive

Pub

lic H

ealth

Pra

ctic

e To

ol)18

Firs

t au

tho

r an

d d

ate

(list

ed

in a

lpha

bet

ical

ord

er)

Sel

ecti

on

bia

sS

tud

y d

esig

nC

onf

oun

der

sB

lind

ing

Dat

a co

llect

ion

met

hod

sW

ithd

raw

als

and

dro

po

uts

Inte

rven

tio

n in

teg

rity

Ana

lysi

sG

lob

al r

atin

g

for

the

pap

er

Altu

n, 2

00821

Wea

kM

oder

ate

Wea

kM

oder

ate

Str

ong

Str

ong

NA

NA

Wea

k

Bal

l, 20

0227

Wea

kS

tron

gW

eak

Mod

erat

eS

tron

gS

tron

gN

AN

AW

eak

Ben

son,

198

928W

eak

Str

ong

Mod

erat

eM

oder

ate

Wea

kS

tron

gN

AN

AW

eak

Cas

erta

, 200

130W

eak

Mod

erat

eN

AM

oder

ate

Wea

kS

tron

gN

AN

AW

eak

Har

tweg

, 198

631W

eak

Mod

erat

eS

tron

gM

oder

ate

Str

ong

Mod

erat

eN

AN

AM

oder

ate

Kem

per

, 198

223W

eak

Str

ong

Str

ong

Mod

erat

eM

oder

ate

Wea

kN

AN

AM

oder

ate

May

, 199

434M

oder

ate

Wea

kN

AM

oder

ate

Wea

kW

eak

NA

NA

Wea

k

Nel

son,

198

429W

eak

Str

ong

Str

ong

Mod

erat

eW

eak

Mod

erat

eN

AN

AW

eak

Por

ter,

1992

20W

eak

Str

ong

Wea

kM

oder

ate

Str

ong

Wea

kN

AN

AW

eak

Rob

erts

, 198

919W

eak

Str

ong

Str

ong

Mod

erat

eW

eak

Wea

kN

AN

AW

eak

Sei

dem

an, 1

99024

Wea

kS

tron

gS

tron

gM

oder

ate

Str

ong

Mod

erat

eN

AN

AM

oder

ate

Sta

rk, 2

00532

Wea

kM

oder

ate

NA

Mod

erat

eS

tron

gW

eak

NA

NA

Wea

k

Tim

mer

man

, 199

933W

eak

Mod

erat

eN

AM

oder

ate

Wea

kS

tron

gN

AN

AW

eak

Vic

kery

,198

825S

tron

gS

tron

gW

eak

Mod

erat

eM

oder

ate

Wea

k

W

eak

Vic

kery

, 198

326W

eak

Str

ong

Str

ong

Mod

erat

eM

oder

ate

Mod

erat

eN

AN

AM

oder

ate

Whi

te, 2

01222

Mod

erat

eM

oder

ate

Mod

erat

eW

eak

Str

ong

Wea

kN

AN

AW

eak

NA

, not

ap

plic

able

.

on August 13, 2020 by guest. P

rotected by copyright.http://gh.bm

j.com/

BM

J Glob H

ealth: first published as 10.1136/bmjgh-2019-001415 on 6 N

ovember 2019. D

ownloaded from

Perera N, Agboola S. BMJ Global Health 2019;4:e001415. doi:10.1136/bmjgh-2019-001415 5

BMJ Global Health

Figure 2 Preferred Reporting Items for Systematic Reviews and Meta- Analyses (PRISMA) flow diagram.

experimental studies19 20 27–29 and cohort studies.21 22 30–33 The type of evaluation design used for 14 of the selected studies included a pre- post design where the follow- up periods varied in length.19–32 The follow- up times ranged from 2 months to 1 year and outcomes were evaluated at multiple points. See table 1 for details of the included studies.

The formal self- care interventions ranged from: univer-sity health promotion courses,21 27 31 33 community- based educative self- care programmes,19 20 22 24 28–30 34 integrated interventions23 and informal interactions.25 26 The target populations of the selected studies were diverse and included university students,21 27 31–33 the elderly,19 28–30 general clinic population,22 23 25 26 the homeless,34 Egyp-tian mothers20 and women experiencing moderate or severe menstrual symptoms.24 The samples were predom-inately female in the selected studies. The methods of data collection varied from self- administered questionnaires,

standardised data collection tools, independent records and interviews. Programme impact was evaluated in five studies19 23 28 30 34 and participation rates were not reported in four studies.19 27 32 34 Three studies19 28 34 had positive programme feedback in increasing health knowledge and changing behaviour. All the studies in this review used self- reported data collection methods where participants were asked to recall their behaviours and express their attitudes on a given topic. The included studies in this review were synthesised under three main categories: effectiveness based on intervention character-istics, impact on health- related outcomes and the cost- effectiveness of the interventions.

Intervention effectiveness based on mode of deliveryIn the four studies that included a university course,21 31–33 lectures were the main method of delivery with group discussions, videos, self- assessments and formulation

on August 13, 2020 by guest. P

rotected by copyright.http://gh.bm

j.com/

BM

J Glob H

ealth: first published as 10.1136/bmjgh-2019-001415 on 6 N

ovember 2019. D

ownloaded from

6 Perera N, Agboola S. BMJ Global Health 2019;4:e001415. doi:10.1136/bmjgh-2019-001415

BMJ Global Health

Tab

le 3

S

umm

ary

of in

clud

ed s

tud

ies

eval

uatin

g th

e ef

fect

iven

ess

of s

elf-

care

inte

rven

tions

in h

ealth

y p

opul

atio

ns

Aut

hor,

year

Co

untr

y

Inte

rven

tio

n ch

arac

teri

stic

s

Par

tici

pan

ts, n

Stu

dy

char

acte

rist

ics

Inte

rven

tio

nTa

rget

po

pul

atio

n an

d s

amp

le s

ize

Stu

dy

des

ign

Eva

luat

ion

des

ign

Res

ults

Qua

lity

asse

ssm

ent

Altu

n, 2

00821

Tu

rkey

Hea

lth p

rom

otio

n co

urse

on

the

enha

ncem

ent

of s

elf-

care

age

ncy

and

he

alth

- pro

mot

ing

beh

avio

urs

thro

ugh

30

hour

s of

cla

ssro

om le

ctur

es v

ia le

ctur

es,

grou

p d

iscu

ssio

ns a

nd in

stru

ctio

nal

vid

eos.

U

nive

rsity

st

uden

ts

41 s

tud

ents

C

ohor

t st

udy

S

ingl

e gr

oup

; pre

- p

ost

eval

uatio

n w

ithin

a 1

5- w

eek

sem

este

r

S

elf-

care

age

ncy

scor

es a

nd

heal

th p

rom

otio

n b

ehav

iour

s al

l sh

owed

sig

nific

ant

incr

ease

aft

er

inte

rven

tion.

W

eak

Bal

l and

Bax

, 20

0227

US

AE

duc

atio

nal i

nter

vent

ion

with

a s

elf-

ca

re c

omp

onen

t in

a c

lass

room

form

at

to p

rom

ote

heal

thy

beh

avio

urs

and

p

ositi

ve e

mot

iona

l ad

just

men

t d

urin

g th

e se

mes

ter.

The

self-

care

inte

rven

tion

was

sup

ple

men

ted

by

self-

awar

enes

s fe

edb

ack

sess

ions

for

som

e p

artic

ipan

ts.

Med

ical

stu

den

ts32

men

and

22

wom

enC

ohor

t st

udy

Pre

- pos

t ev

alua

tion

des

ign

Thos

e in

the

sel

f- ca

re in

terv

entio

n ha

d

a hi

gher

like

lihoo

d o

f hav

ing

cons

iste

nt

slee

pin

g tim

es, i

ncre

ased

exe

rcis

e fr

eque

ncy

and

less

tro

uble

falli

ng

asle

ep, b

ut a

lcoh

ol c

onsu

mp

tion

was

no

t af

fect

ed.

Wea

k

Ben

son

et a

l, 19

8928

US

A‘S

tayi

ng H

ealth

y A

fter

Fift

y’; a

nat

ionw

ide

educ

atio

nal p

rogr

amm

e fo

r th

e el

der

ly

bas

ed o

n a

pre

viou

s p

rogr

amm

e co

mp

risin

g 11

ses

sion

s.

Gen

eral

eld

erly

p

opul

atio

n16

1 in

terv

entio

n p

artic

ipan

ts16

4 co

ntro

l gro

up

par

ticip

ants

Qua

siex

per

imen

tal

tria

lIn

terv

entio

n an

d

cont

rol g

roup

; pre

- p

ost

eval

uatio

n w

ith

a 6-

mon

th fo

llow

- up

The

inte

rven

tion

grou

p s

core

d h

ighe

r in

hea

lth s

kills

, hea

lth a

ctio

ns a

nd

heal

th c

osts

sca

le. T

he im

pro

vem

ent

cont

inue

d o

ver

time.

Wea

k

Cas

erta

et

al,

2001

30U

SA

‘Pat

hfind

ers’

is a

form

al s

elf-

care

and

he

alth

ed

ucat

ion

pro

gram

me

for

old

er

wid

ows

and

wid

ower

s co

verin

g a

rang

e of

hea

lth- p

r om

otiv

e to

pic

s in

11

wee

ks.

Del

iver

ed b

y ex

per

ts in

a c

lass

room

fo

rmat

usi

ng le

ctur

es, g

roup

dis

cuss

ion,

go

al s

ettin

g ex

erci

ses

and

dis

trib

utin

g w

ritte

n in

form

atio

n. A

grie

f cou

nsel

lor

was

al

so p

rese

nt.

Old

er w

idow

s an

d

wid

ower

s84

wid

ows

and

w

idow

ers

Coh

ort

stud

yS

ingl

e gr

oup

; pre

- p

ost

eval

uatio

n w

ith

2 an

d 4

mon

ths’

fo

llow

- up

The

atte

ndan

ce r

ate

for

the

pro

gram

me

was

71%

and

par

ticip

ants

sco

red

hi

gh o

n b

ehav

iour

al in

tent

ion

and

b

ehav

iour

al a

ttitu

de.

Lea

rnin

g to

ta

ke c

are

of t

hem

selv

es w

as t

he

mos

t im

por

tant

ben

efit

for

the

stud

y p

artic

ipan

ts.

Wea

k

Har

tweg

and

M

etca

lfe,

1986

31

US

AS

elf-

care

cur

ricul

um b

ased

on

Ore

m's

se

lf- ca

re d

efici

ent

theo

ry w

hich

w

as in

corp

orat

ed t

o th

e un

iver

sity

co

urse

s th

roug

hout

the

nur

sing

deg

ree

pro

gram

me.

Nur

sing

stu

den

ts40

nur

sing

stu

den

ts

and

71

non-

nurs

ing

stud

ents

Coh

ort

stud

yP

re- p

ost

des

ign;

b

egin

ning

of t

he

pro

gram

me

and

fo

llow

- up

aft

er 3

ye

ars

once

the

co

urse

was

ove

r .

Nur

sing

stu

den

ts h

ad a

sig

nific

antly

st

rong

er a

ttitu

de

tow

ard

s se

lf- ca

re

than

non

- nur

sing

stu

den

ts. A

rea

of

resi

den

ce is

a c

onfo

und

ing

fact

or.

Mod

erat

e

Kem

per

, 198

223U

SA

An

info

rmal

sel

f- ca

re e

duc

atio

nal

pro

gram

me

of 1

0 se

ssio

ns t

arge

ting

sym

pto

m m

onito

ring,

life

styl

e ch

ange

s an

d c

onfid

ence

bui

ldin

g. It

was

led

by

a nu

rse

pra

ctiti

oner

and

rea

din

g m

ater

ial

was

pro

vid

ed.

Gen

eral

pop

ulat

ion

Exp

erim

enta

l gr

oup

:107

fam

ilies

Con

trol

gro

up: 1

10

fam

ilies

Ran

dom

ised

co

ntro

lled

tria

lP

re- p

ost

des

ign

with

6

and

12

mon

ths’

fo

llow

- up

Sel

f- ca

re k

now

led

ge in

crea

sed

by

125%

in t

he in

terv

entio

n gr

oup

and

on

ly 8

% in

the

con

trol

gro

up. T

he

incr

emen

t w

as c

onsi

sten

t d

urin

g b

oth

follo

w- u

p p

erio

ds.

The

inte

rven

tion

was

als

o sh

own

to b

e co

st- e

ffect

ive

in t

hat

the

inte

rven

tion

grou

p a

ccru

ed

less

med

ical

cos

ts t

han

the

cont

rol

grou

p.

Mod

erat

e

May

and

E

vans

, 199

434U

SA

Hea

lth e

duc

atio

n p

rogr

amm

e w

ith a

he

alth

pro

mot

ion

and

pre

vent

ion

focu

s fo

r kn

own

heal

th p

rob

lem

s of

the

hom

eles

s.

It w

as c

ond

ucte

d in

a c

lass

room

form

at

usin

g le

ctur

es a

nd p

rese

ntat

ions

by

com

mun

ity h

ealth

nur

ses.

Hom

eles

s p

opul

atio

n24

04 h

omel

ess

clie

nts

from

13

urb

an s

helte

rs a

nd

trea

tmen

t si

tes

Cro

ss- s

ectio

nal

stud

yR

epea

ted

q

uest

ionn

aire

s gi

ven

to t

he p

artic

ipan

ts

over

the

inte

rven

tion

per

iod

of 1

8 m

onth

s.

98%

of t

he p

artic

ipan

ts fo

und

the

p

rese

ntat

ions

to

be

usef

ul. P

ositi

ve

pro

gram

me

eval

uatio

n w

as a

ssum

ed

to h

ave

pos

itive

out

com

es.

Wea

k Con

tinue

d

on August 13, 2020 by guest. P

rotected by copyright.http://gh.bm

j.com/

BM

J Glob H

ealth: first published as 10.1136/bmjgh-2019-001415 on 6 N

ovember 2019. D

ownloaded from

Perera N, Agboola S. BMJ Global Health 2019;4:e001415. doi:10.1136/bmjgh-2019-001415 7

BMJ Global Health

Aut

hor,

year

Co

untr

y

Inte

rven

tio

n ch

arac

teri

stic

s

Par

tici

pan

ts, n

Stu

dy

char

acte

rist

ics

Inte

rven

tio

nTa

rget

po

pul

atio

n an

d s

amp

le s

ize

Stu

dy

des

ign

Eva

luat

ion

des

ign

Res

ults

Qua

lity

asse

ssm

ent

Nel

son

et a

l, 19

8429

US

AA

sel

f- ca

re e

duc

atio

n p

rogr

amm

e w

ith

13 c

lass

es w

ith r

einf

orce

men

t ac

tiviti

es

that

con

tinue

d fo

r a

year

whe

re c

linic

al

med

icin

e, li

fest

yle

and

ind

epen

den

t liv

ing

wer

e al

l ad

dre

ssed

. It

was

del

iver

ed b

y a

trai

ned

tea

m t

hrou

gh g

roup

dis

cuss

ions

, sk

ill t

rain

ing,

rol

e- p

layi

ng a

nd s

elf-

co

ntra

ctin

g.

Eld

erly

pop

ulat

ion

341

ind

ivid

uals

from

N

ew H

amp

shire

Qua

siex

per

imen

tal

tria

lIn

terv

iew

s w

ere

cond

ucte

d b

y tr

aine

d

inte

rvie

wer

s an

d a

sk

ills

per

form

ance

w

as c

ond

ucte

d a

fter

in

terv

entio

n an

d a

t 1-

year

follo

w- u

p.

Inte

rven

tion

grou

p s

how

ed m

ore

confi

den

ce in

sel

f- ca

re t

asks

and

the

ga

ins

did

not

dec

reas

e ov

er t

ime.

Th

e lif

esty

le c

hang

es a

ttem

pte

d w

ere

high

er fo

r th

e in

terv

entio

n gr

oup

but

th

ese

incr

emen

ts d

id n

ot s

usta

in o

ver

time.

Wea

k

Por

ter

et a

l, 19

9220

Egy

pt

‘Par

enta

l Enh

ance

men

t P

rogr

am,’

an

educ

atio

nal s

upp

ortiv

e p

rogr

amm

e w

hich

in

clud

ed s

yste

mat

ical

ly p

lann

ed c

lass

es

del

iver

ed fa

ce t

o fa

ce u

sing

dis

cuss

ions

an

d r

ole-

pla

y.

Egy

ptia

n m

othe

rs58

mot

hers

Qua

siex

per

imen

tal

tria

lP

re- p

ost

eval

uatio

n d

esig

n w

ith 3

m

onth

s, 6

and

12

mon

ths’

follo

w- u

p.

Sel

f- ca

re a

genc

y, s

elf-

este

em a

nd

mat

erna

l per

cep

tion

show

ed n

o ch

ange

s in

the

inte

rven

tion

grou

p. T

he

cont

rol g

roup

sho

wed

pos

itive

sel

f-

care

age

ncy

and

sel

f- es

teem

sco

res.

Wea

k

Rob

erts

et

al,

1989

19Is

land

s of

H

awai

i, O

ahu

and

M

aui

‘Sta

ying

Hea

lthy

Aft

er F

ifty,

’ a n

atio

nwid

e ed

ucat

iona

l pro

gram

me

for

the

eld

erly

of

11 s

essi

ons

cultu

rally

ad

apte

d t

o su

it th

e H

awai

i Asi

an- A

mer

ican

pop

ulat

ion.

Eld

erly

pop

ulat

ion

89 q

uest

ionn

aire

s fr

om t

he c

ours

e gr

oup

166

que

stio

nnai

res

from

the

com

par

ison

gr

oup

Qua

siex

per

imen

tal

tria

lP

re- p

ost

eval

uatio

n d

esig

n w

ith 3

and

6

mon

ths’

follo

w- u

p

Cou

rse

par

ticip

ants

sco

red

hig

her

in

heal

th s

kills

, hea

lth a

ctio

ns, h

ealth

care

co

sts

and

use

of m

edic

al r

efer

ence

b

ook.

The

imp

rove

men

ts c

ontin

ued

ov

er t

ime

as w

ell.

Wea

k

Sei

dem

an,

1990

24U

SA

‘Pre

men

stru

al S

ynd

rom

e E

duc

atio

nal

Pro

gram

’ don

e in

a c

lass

room

set

ting

usin

g p

rese

ntat

ions

. Inf

orm

atio

n se

ssio

ns o

n P

MS

, life

styl

e d

iscu

ssio

ns

and

boo

klet

s w

ere

used

to

dis

sem

inat

e in

form

atio

n.

Wom

en

exp

erie

ncin

g m

oder

ate

to

seve

re P

MS

sy

mp

tom

s

47 w

omen

Coh

ort

stud

yP

MS

sym

pto

ms

wer

e re

cord

ed

over

3 m

onth

s an

d

par

ticip

ants

wer

e co

ntac

ted

at

2-

wee

k in

terv

als

for

rein

forc

emen

t.

The

inte

rven

tion

grou

p r

epor

ted

si

gnifi

cant

ly lo

wer

occ

urre

nces

of

PM

S s

ymp

tom

s, lo

wer

sev

erity

of t

he

sym

pto

ms

and

less

er n

umb

er o

f day

s w

ith p

rem

enst

rual

sym

pto

ms.

Mod

erat

e

Sta

rk e

t al

, 20

0532

US

A‘N

urse

's R

ole

in F

acili

tatin

g H

ealth

and

S

elf-

Car

e,’ a

sem

este

r- lo

ng e

duc

atio

nal

univ

ersi

ty s

elf-

care

cou

rse

that

incl

uded

a

lifes

tyle

sel

f- ca

re p

lan

and

a s

elf-

care

as

sess

men

t d

eliv

ered

in a

cla

ssro

om

form

at.

Nur

sing

stu

den

ts67

nur

sing

stu

den

tsC

ohor

t st

udy

Sin

gle

grou

p; p

re-

pos

t ev

alua

tion

with

a

mid

- sem

este

r an

d

end

- of-

sem

este

r ev

alua

tion

Par

ticip

ants

sig

nific

antly

cha

nged

the

ir lif

esty

le b

ehav

iour

s an

d o

lder

stu

den

ts

had

mor

e he

alth

- pro

mot

ing

beh

avio

urs

and

hea

lth r

esp

onsi

bili

ty.

Wea

k

Tim

mer

man

, 19

9933

US

AH

ealth

pro

mot

ion

cour

se fo

cuse

d

on d

evel

opin

g a

lifes

tyle

sel

f- ca

re

pla

n (L

SC

P) d

eliv

ered

in a

cla

ssro

om

form

at, c

over

ing

heal

th p

rom

otio

n to

pic

s of

nut

ritio

n, e

xerc

ise

and

str

ess

man

agem

ent.

Nur

sing

stu

den

ts95

stu

den

tsC

ohor

t st

udy

Mid

- pos

t ev

alua

tion

with

a 6

- mon

th

follo

w- u

p

Imm

edia

tely

aft

er t

he in

terv

entio

n on

ly

42.1

% h

ad a

chie

ved

the

ir go

al. A

t th

e 6

mon

ths’

follo

w- u

p 5

2% o

f the

p

artic

ipan

ts h

ad a

chie

ved

the

ir lif

esty

le

goal

s.

Wea

k

Vic

kery

et

al,

1988

25U

SA

The

self-

care

inte

rven

tion

was

a m

ixed

in

terv

entio

n w

ith t

hree

op

tions

of w

ritte

n m

ater

ials

, tel

epho

ne in

form

atio

n se

rvic

e an

d a

n in

div

idua

l cou

nsel

ling

sess

ion.

Gro

up 1

: writ

ten

mat

eria

ls, t

elep

hone

se

rvic

e an

d in

div

idua

l cou

nsel

ling.

Gro

up 2

: writ

ten

mat

eria

ls a

nd t

elep

hone

se

rvic

e.G

roup

3: w

ritte

n m

ater

ials

onl

y.G

roup

4: n

o in

terv

entio

n

Gen

eral

pop

ulat

ion

1625

hou

seho

lds

Ran

dom

ised

co

ntro

lled

tria

lP

re- p

ost

eval

uatio

n d

esig

n w

ith 1

2 m

onth

s’ fo

llow

- up

All

exp

erim

enta

l gro

ups

show

ed a

si

gnifi

cant

dec

reas

e in

am

bul

ator

y ca

re

utili

satio

n in

com

par

ison

to

the

cont

rol

grou

p. T

he in

terv

entio

n w

as fo

und

to

be

cost

- ef fe

ctiv

e in

com

par

ison

to

usu

al o

r no

car

e. T

he t

elep

hone

in

form

atio

n se

rvic

e w

as n

ot u

sed

as

antic

ipat

ed (<

20 c

alls

per

yea

r).

Mod

erat

e

Tab

le 3

C

ontin

ued

Con

tinue

d

on August 13, 2020 by guest. P

rotected by copyright.http://gh.bm

j.com/

BM

J Glob H

ealth: first published as 10.1136/bmjgh-2019-001415 on 6 N

ovember 2019. D

ownloaded from

8 Perera N, Agboola S. BMJ Global Health 2019;4:e001415. doi:10.1136/bmjgh-2019-001415

BMJ Global Health

Aut

hor,

year

Co

untr

y

Inte

rven

tio

n ch

arac

teri

stic

s

Par

tici

pan

ts, n

Stu

dy

char

acte

rist

ics

Inte

rven

tio

nTa

rget

po

pul

atio

n an

d s

amp

le s

ize

Stu

dy

des

ign

Eva

luat

ion

des

ign

Res

ults

Qua

lity

asse

ssm

ent

Vic

kery

et

al,

1983

26U

SA

‘Coo

per

ativ

e H

ealth

Ed

ucat

ion

Pro

gram

me’

aim

ed t

o as

sess

med

ical

ca

re u

tilis

atio

n us

ing

a w

ritte

n m

ater

ial

and

a t

elep

hone

info

rmat

ion

serv

ice.

Gen

eral

pop

ulat

ion

1249

ind

ivid

uals

Ran

dom

ised

co

ntro

lled

tria

lP

re- p

ost

des

ign

with

6

and

12

mon

ths’

fo

llow

- up

Sig

nific

ant

red

uctio

ns in

tot

al

amb

ulat

ory

visi

ts a

nd a

dec

reas

e in

all

med

ical

car

e p

rovi

der

util

isat

ions

by

the

inte

rven

tion

grou

p. T

he t

elep

hone

in

form

atio

n se

rvic

e w

as n

ot u

sed

as

antic

ipat

ed. W

ritte

n m

ater

ial w

as u

sed

th

e m

ost.

Wea

k

Whi

te e

t al

, 20

1222

UK

A p

olic

y- d

riven

com

mun

ity s

elf-

care

in

terv

entio

n ex

plo

ring

the

attit

udes

an

d s

kills

rel

ated

to

self-

car e

and

he

alth

care

del

iver

ed b

y S

elf C

are

Sup

por

t C

oord

inat

ors

in P

rimar

y C

are

Trus

ts in

sm

all g

roup

ses

sion

s.

Gen

eral

pop

ulat

ion

1568

par

ticip

ants

w

ere

incl

uded

in t

he

stud

y.

Qua

siex

per

imen

tal

tria

l—co

hort

stu

dy

Pre

que

stio

nnai

re w

ith

6 an

d 1

2 m

onth

s’

follo

w- u

p. P

artic

ipan

t he

alth

dat

a w

ere

anal

ysed

1 y

ear

bef

ore

the

stud

y as

w

ell.

No

det

ecta

ble

diff

eren

ces

in t

he

num

ber

of G

P c

onsu

ltatio

ns o

r p

erce

ived

hea

lth s

tatu

s. S

mal

l pos

itive

ef

fect

s on

psy

chol

ogic

al o

utco

mes

th

at in

clud

e se

lf- es

teem

, anx

iety

and

su

bje

ctiv

e w

ell-

bei

ng.

Wea

k

GP,

gen

eral

pra

ctiti

oner

; PM

S, p

rem

enst

rual

syn

dro

me.

Tab

le 3

C

ontin

ued

of lifestyle self- care plans used to enhance learning. All four studies had positive effects in improving self- care behaviour, with three of them showing improvements in other health- related outcomes.21 31 32 Eight studies used face- to- face interventions and positive changes in health- promotive outcomes were in four studies.23 24 30 34 However, interventions that were exclusively face to face had no significant impact on medical care utilisation22 or on health- related outcomes.20

Written materials combined with other methods were used to conduct the intervention in seven studies. Signifi-cant improvement in self- care behaviour and other health outcomes was seen in six of the seven studies with mixed findings in the remaining one. Two of the 16 included studies used written materials with a telephone service,25 and written materials with one- on- one counselling.26 Although the telephone service had very limited use in both studies, a significant decrease in the utilisation of medical services was measured in both. In the intervention group that used written material only as in the mode of informa-tion delivery, it was reported to be more cost- effective when combined with one- on- one counselling.26

effectiveness on health-related outcomesSelf- care interventions were found to be most effec-tive among elderly populations19 28–30 and student cohorts,21 27 31–33 with mixed findings among the general population studies.22 23 25 26 The change in lifestyle behaviour was maintained in follow- up in two out of the three19 28 studies that targeted elderly populations.

Given the heterogeneity of the interventions analysed for this review, there were numerous outcome measures considered. Overall, self- care behaviours that include self- care attitudes, self- care knowledge, self- care strategies and self- care agency were evaluated explicitly in seven studies.20 21 23 25 29 31 33 Outcomes related to health knowl-edge, health behaviour, changes in attitudes and lifestyle changes were measured in nine studies.19 21 25 27–30 32 33 Only one study conducted a process evaluation.34 Util-isation of medical services, which included visits to the GP, ambulatory care, emergency and laboratory care, was measured in seven studies19 22 23 25 26 28 29 and cost- effectiveness of the intervention was measured in three studies.23 25 26 Demographic data were collected from all studies but one.34 Other outcomes assessed in the studies were participation rates, depression, maternal percep-tion, self- esteem and programme evaluation outcomes.

Out of the seven studies that examined overall self- care behaviour as an outcome, four studies showed an improvement in self- care behaviour.21 23 29 31 A significant positive increase in self- care knowledge and attitudes and increased confidence to perform self- care tasks like emer-gency self- checks which included checking for pulse, swollen glands and performing the Heimlich manoeuvre and sustained effects of the improvement in self- care behaviour was highlighted in three studies.23 29 31 One study targeting mothers of lower SES showed a negative impact on self- care behaviour after the intervention.20

on August 13, 2020 by guest. P

rotected by copyright.http://gh.bm

j.com/

BM

J Glob H

ealth: first published as 10.1136/bmjgh-2019-001415 on 6 N

ovember 2019. D

ownloaded from

Perera N, Agboola S. BMJ Global Health 2019;4:e001415. doi:10.1136/bmjgh-2019-001415 9

BMJ Global Health

Lifestyle behaviours such as exercise, stress manage-ment, nutrition habits, sleeping behaviour and alcohol consumption were measured in seven studies.19 21 27–29 32 33 Two of those studies21 32 used the Health- Promoting Life-style Plan- II scale as a measurement tool. After the inter-vention, a significant improvement in health- promoting lifestyle changes including health skills and actions was detected in four of the seven studies.19 21 28 32 Improved sleeping behaviour and increased exercise frequency was observed in the study by Ball and Bax but no differences in alcohol consumption were detected.27

Health attitudes including beliefs and perceptions were examined in four studies19 22 28 30 where thoughts about one’s emotional self and cognition were recorded. The outcomes showed mixed impact with only small positive effects on anxiety, self- esteem, health literacy and recovery locus control.22 Other health outcomes that were evaluated in the studies included premen-strual syndrome symptoms, self- esteem, emotional and academic adjustment and depression which showed no significant or sustained changes over time.20 24 27 Addi-tionally, an increased ability to communicate with the physician was reported in one study.29

Cost-effectiveness of the interventionsOnly 3 of the 16 studies measured cost- effectiveness. In all three, the intervention groups accrued less health costs compared with the control group.23 25 26 For example, two different studies by Vickery et al on medical self- care education for elders showed cost- benefit ratios of $2.1925 and $2.29–$3.29,26 respectively, for every dollar spent on the intervention. Furthermore, the savings due to decreased medical visits exceeded the intervention costs significantly. Kemper,23 in their informal self- care educa-tional programme, also found that the intervention group was more cost- effective than the control group with a cost difference of about $2.22 between the groups. In Kemper’s study, cost savings per family were $55.25 which calculated a cost saving of $101.27 per participant.23 Significant decreases in hospital and minor illness care utilisation were also reported.26 Further, studies done in the USA25 26 showed decreased medical care utilisation although the UK study showed no change in the number of GP visits.22

dIsCussIonThe aim of this review was to explore the overall effec-tiveness of preventative formal self- care programmes for healthy populations in improving health outcomes. The pooled effects of the 16 studies included in this review found mixed evidence for the effectiveness of preventa-tive self- care interventions. Six of the 16 studies included in this review explicitly examined self- care behaviour with four showing improvements in self- care- related behaviour after intervention. Similarly, six of the eight studies that measured health- promotive behavioural change showed positive improvement. Health beliefs and

attitudes showed little or no significant change. Self- care interventions were most effective among elderly popula-tions and student cohorts, with mixed findings among the general population. Interventions were found to be cost- effective in comparison to no or usual care in all the three studies that reported this. 87.5% of the included studies in this review are from HICs with 75% from the USA. Only two studies (12.5%) are from low/middle- income countries (LMIC). This indicates that self- care and health promotion for healthy populations is more recognised as a health concern and priority in HICs than LMICs.

Despite the studies in this review having used designs that are considered to be strong or ‘gold standard’, (RCTs, quasiexperimental or cohort), the generalisability of their results is limited due to sampling and reporting biases, and the lack of consideration for confounding factors. Eight of the 16 studies had small samples and relied on convenience sampling methods which included self- selection of the participants, introducing a volunteer bias. The other eight studies with larger samples had high dropout rates and low participation at follow- up points. The role of the researcher was overlooked in 13 studies where blinding was not discussed at the interven-tion stages nor in the analysis stages. Furthermore, there was a lack of consideration for confounding factors such as gender, age and level of education which could impact the transferability of the outcomes in practice.

Recording and understanding long- term behaviour change is an existing challenge in the field of health promotion.35 The varied and inconsistent patterns of follow- up in the included studies limited the ability of this review to draw conclusive inferences about long- term behaviour change.35 A systematic review done in 2011 by Fjeldsoe et al exploring maintenance of behaviour in exercise and dietary changes showed that only 35% of intervention trials reported maintenance outcomes, and highlighted the importance of recording, reporting and developing a common understanding of behaviour maintenance.36 Additionally, a study by Ryan et al, exam-ining the relationship between health behaviour and the self- determination theory,37 showed that addressing an individual’s psychological needs such as autonomy, relat-edness and competence results in increased engagement and maintenance in health behaviour. Thus, interven-tions rooted in health promotional theories38 that address psychological factors in behaviour change could address the limitations in sustained health behaviour change.

Consistent with previous work by Deeks et al39 on the effects of gender and age on health behaviours and Acton and Malathum in 2000 on health- promotive self- care behaviour in adults,5 this review found that self- care interventions were most effective in elderly populations. This could potentially be due to their increased engage-ment with health and social care services compared with younger individuals. Furthermore, as observed in other studies5 36 positive lifestyle behaviour changes were more likely to be sustained in older population groups

on August 13, 2020 by guest. P

rotected by copyright.http://gh.bm

j.com/

BM

J Glob H

ealth: first published as 10.1136/bmjgh-2019-001415 on 6 N

ovember 2019. D

ownloaded from

10 Perera N, Agboola S. BMJ Global Health 2019;4:e001415. doi:10.1136/bmjgh-2019-001415

BMJ Global Health

compared with the general population.5 38 This is in line with health promotion theories which posit that younger individuals may have less incentive and motivation to sustain healthy lifestyle behaviours. This could be due to optimistic bias, where one perceives that they are less likely to experience a negative event, or social and cultural influences that limit younger people engage in health- promoting behaviour.38

This review also indicates that the interventions were effective in improving self- care and health- promotive behaviour in university students. As the interventions were integrated into academic work, student popula-tions may have a higher incentive to be more compliant to self- care interventions than the general population. Furthermore, the special interest of self- care in nursing students could have additional explanations including that self- care practices are mostly promoted and taught by nurses in clinical settings.32 This increases the need for nursing staff to have insight to the practice of devel-oping self- care behaviour plans.32 33 Nonetheless, studies with medical students have shown more limited effec-tiveness and poorer health behaviours,40 which could be attributed to the nature of the work in the health sector and its various stressors.

Differences in healthcare systems and methods of financing impact on uptake and sustainability of health- promoting self- care behaviour. This is highlighted in the interventions done in the USA which showed decreased medical care utilisation, with no changes in the number of GP visits for the intervention participants in the UK study.22 25 26 An analysis of the Organisation for Economic Co- operation Development healthcare utilisation rates in 201641 showed that health systems that are financed through public funds like in the UK have increased util-isation rates. On the contrary, privately financed health systems, like in the USA, may have the ‘unintended consequence’ of encouraging communities to be more responsive to health interventions due to the direct finan-cial impact of accessing medical services.41 42 The role of the broader healthcare system is an area that warrants further investigation. This may provide insight into the impact that the levels of dependency on healthcare and its wider determinants of health- promoting self- care ideologies exist among different populations.5 6

Majority of interventions in this review had a face- to- face component in delivery supplemented with written materials and demonstrations. These multicomponent interventions were shown to be more effective than those that were face to face only. Works by Kaufman et al43 and Kiropoulos et al44 indicate that the impact of face- to- face only interventions in changing health knowledge and behaviour is mixed and dependent on the target behaviour of the intervention, suggesting a need for multicomponent interventions. This review also showed that interventions comprising only written materials were as effective as other interventions that used more engaging techniques, specifically in terms of medical service utilisation. This could have been due to the fact

that most of the interventions were group based. Group dynamics have been shown to impact on communica-tion45 which could potentially limit the effectiveness of face- to- face communication. In contrast to the findings of this study, a systematic review conducted on the effec-tiveness of multifaceted interventions by Squires et al46 showed limited support for multicomponent interven-tions in comparison to single constituent interventions. This suggests a need for further research examining the effectiveness of different modes and approaches of inter-vention delivery.

limitationsA key limitation of this review was that the majority of studies that were included were published in the 1980s and 1990s. One explanation for the lack of recent studies could be the change and overlap in terminology used in preventative self- care and health education. Over time, terms such as self- management, self- help, self- efficacy and health education have been used synonymously with self- care. Also, many of the recent interventions that focus on prevention do not explicitly mention self- care as a primary outcome, but address specific aspects of self- care behaviour such as exercise, nutritional habits, sleep patterns or hygiene.47 48 This means that rarely will overall self- care as an outcome in and of itself be evaluated in a formal systematic manner.

Furthermore, this change in terminology over time and lack of a ‘globally accepted’ definition for formal self- care interventions created a significant challenge for the authors in limiting the boundaries of the articles to be included in this review. Hence, this review was limited to formal interventions that explicitly looked at ‘self- care’ as a labelled outcome. While this could have had an impact on the comprehensiveness of the included studies in this review, it is also an indication of the interchangeability of terminology and lack of formal definition for self- care vari-ables in the field of health promotion. Additionally, there was an over- representation of studies from North America (specifically the USA) with little or no representation from all other regions, highlighting the dearth in literature in health- promotive self- care programmes for healthy popula-tions in other regions and particularly in LMICs.

Cultural beliefs and appropriateness are key consider-ations in understanding the health promotion climate of a setting and play a significant role in health beliefs and behaviour change.49 The studies included in this review generally did not consider culture and its impact on health- promotive self- care behaviour. Thus, the effectiveness and impact of the interventions may be limited as placebo effects that stem from cultural beliefs and implicit personal practices were not captured in these studies.

ConClusIonSelf- care initiatives are being encouraged as an impor-tant part of healthcare in various forms across the globe.50 This review contributes important knowledge to the effectiveness of existing programmes that target

on August 13, 2020 by guest. P

rotected by copyright.http://gh.bm

j.com/

BM

J Glob H

ealth: first published as 10.1136/bmjgh-2019-001415 on 6 N

ovember 2019. D

ownloaded from

Perera N, Agboola S. BMJ Global Health 2019;4:e001415. doi:10.1136/bmjgh-2019-001415 11

BMJ Global Health

healthy populations. Nonetheless, the overall evaluation of self- care interventions could be improved if quantita-tive outcomes were measured using standardised scales, combined with qualitative evidence to capture target users’ perspectives. There is a need to develop a system-atic framework to define, understand and implement health- promotive self- care interventions across different healthcare settings, and to develop a common global defi-nition for self- care and management. Long- term behav-iour change and maintenance should be prioritised in intervention design with consensus among healthcare entities on how to report and measure outcomes over time.

As this review highlights, the cost- effectiveness of health- promotive self- care and reduction of utilisation of medical services could significantly reduce health-care expenditure. As self- care ideologies vary among health systems, further economic studies that include using quality- adjusted life- years, disability- adjusted life- years and economic modelling techniques would help improve understanding of the cost- effectiveness of such interventions. Given the mixed evidence in single versus multicomponent approaches and in general popula-tion studies compared with targeted subgroups, special consideration should be given to the methods employed in delivering health- promotive self- care information and to the demographic backgrounds of the target users. This review is a stepping stone to exploring the different aspects involved in designing and implementing self- care interventions for healthy populations. It also supports a call to action for public health and academic personnel to recognise the gaps and inconsistencies in the existing forms of self- care and the ideologies that govern it, in order to make well- informed decisions in health promotion.

Acknowledgements This publication was funded by Alliance for Health Policy and Systems Research, an international partnership hosted by the World Health Organization, with support from the Norwegian Government Agency for Development Cooperation (Norad), the Swedish International Development Cooperation Agency (Sida) and the UK Department for International Development (DFID). The authors acknowledge Dr Kui W Muraya from the KEMRI Wellcome Trust Research Programme in Kenya, who provided mentorship to NP as a part of the AHPSR research mentorship programme to develop this publication.

Contributors The study idea was developed and discussed between NP and SA. The review design and methodology was developed by both. The review was conducted by NP with the close supervision of SA. NP led the development of the manuscript for publication.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not- for- profit sectors.

Competing interests None declared.

Patient consent for publication Not required.

Provenance and peer review Not commissioned; externally peer reviewed.

data sharing statement Data are available upon reasonable request.

open access This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY- NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non- commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non- commercial. See: http:// creativecommons. org/ licenses/ by- nc/ 4. 0/.

REFEREnCES 1. McGinnis JM, Williams- Russo P, Knickman JR. The case for

more active policy attention to health promotion. Health Affairs 2002;21:78–93.

2. Kickbusch I. The contribution of the World Health organization to a new public health and health promotion. Am J Public Health 2003;93:383–8.

3. Simmons SJ. The health- promoting self- care system model: directions for nursing research and practice. Journal of Advanced Nursing 1990;15:1162–6.

4. United Nations. Sustainable development Goals. sustainable development knowledge platform (Internet), 2015. Available: https:// sust aina bled evel opment. un. org/? menu= 1300 [Accessed 20 Jun 2017].

5. Acton GJ, Malathum P. Basic need status and health- promoting self- care behavior in adults. Western Journal of Nursing Research 2000;22:796–811.

6. Weintraub WS, Daniels SR, Burke LE, et al. Value of primordial and primary prevention for cardiovascular disease a policy.

7. Self- care Forum. What do we mean by self care and why is it good for people? 2016. Available: http://www. selfcareforum. org/ about- us/ what- do- we- mean- by- self- care- and- why- is- good- for- people/ [Accessed 10 Jun 2016].

8. Morrell DC, Avery AJ, Watkins CJ. Management of minor illness. BMJ 1980;280:769–71.

9. Watson M, Blair M. Emergency departments and minor illness: some behavioural insights. Arch Dis Child 2018;103:309–10.

10. Gustafsson S, Vikman I, Axelsson K, et al. Self- care for minor illness. Prim Health Care Res Dev 2015;16:71–8.

11. Powers BJ, Olsen MK, Oddone EZ, et al. The effect of a hypertension self- management intervention on diabetes and cholesterol control. The American Journal of Medicine 2009;122:639–46.

12. Dean K. Self- care components of lifestyles: the importance of gender, attitudes and the social situation. Social Science & Medicine 1989;29:137–52.

13. Dean K. Special Issue Health Self- care components of lifestyles: the importance of gender, attitudes and the social situation. Soc Sci Med 1989;29:137–52.

14. Gillis AJ. Determinants of a health- promoting lifestyle: an integrative review. Journal of Advanced Nursing 1993;18:345–53.

15. Popay J, Roberts H, Sowden A, et al. Guidance on the conduct of narrative synthesis in systematic reviews. A product from the ESRC methods programme Version 2006;1.

16. Higgins JPT, Green S. Cochrane Handbook for systematic reviews of interventions: Wiley online library, 2008.

17. Moher D, Liberati A, Tetzlaff J. Preferred reporting items for systematic reviews and meta- analyses: the PRISMA statement. Annals of Internal Medicine 2009;151:264–9.

18. Effective Public Health Practice Project. Quality Assessment Tool for Quantitative Studies(Internet), 1998. Available: http://www. ephpp. ca/ PDF/ Quality Assessment Tool_ 2010_ 2. pdf. [Accessed 20 Jun 2016].

19. Roberts E, Takenaka JI, Ross CJ, et al. Hawaii Asian- American response to the staying healthy after fifty program. Health Education Quarterly 1989;16:509–27.

20. Porter LS, Youssef M, Shaaban I, et al. Parenting enhancement among Egyptian mothers in a tertiary care setting. Pediatric Nursing 1992;18:329–51.

21. Altun I. Effect of a health promotion course on health promoting behaviours of university students. East Mediterr Health J 2008;14:880–7.

22. White A, South J, Bagnall A- M, et al. The self- care for people Initiative: the outcome evaluation. Prim Health Care Res Dev 2012;13:382–94.

23. Kemper DW. Self- care education: impact on HMO costs. Med Care 1982;20:710–8.

24. Seideman RY. Effects of a premenstrual syndrome education program on premenstrual symptomatology. Health Care for Women International 1990;11:491–501.

25. Vickery DM, Golaszewski TJ, Wright EC, et al. The effect of self- care interventions on the use of medical service within a Medicare population. Medical Care 1988;26:580–8.

26. Vickery DM, Kalmer H, Lowry D. Effect of a self- care education program on medical visits. JAMA 1983;250:2952–6.

27. Ball S, Bax A. Self- care in medical education: effectiveness of health- habits interventions for first- year medical students. Acad Med 2002;77:911–7.

28. Benson L, Nelson EC, Napps SE, et al. Evaluation of the staying healthy after fifty educational program: impact on course participants. Health Education Quarterly 1989;16:485–508.

on August 13, 2020 by guest. P

rotected by copyright.http://gh.bm

j.com/

BM

J Glob H

ealth: first published as 10.1136/bmjgh-2019-001415 on 6 N

ovember 2019. D

ownloaded from

12 Perera N, Agboola S. BMJ Global Health 2019;4:e001415. doi:10.1136/bmjgh-2019-001415

BMJ Global Health

29. Nelson EC, McHugo G, Schnurr P, et al. Medical self- care education for elders: a controlled trial to evaluate impact. American Journal of Public Health 1984;74:1357–62.

30. Caserta MS, Lund DA, Rice SJ. Participants' attendance at a health promotion program for older widows and widowers. American Journal of Health Education 2001;32:229–36.

31. Hartweg DL, Metcalfe SA. Self- care attitude changes of nursing students enrolled in a self- care curriculum—A longitudinal study. Res. Nurs. Health 1986;9:347–53.

32. Stark MA, Manning- Walsh J, Vliem S. Caring for self while learning to care for others: a challenge for nursing students. Journal of Nursing Education 2005;44:266–70.

33. Timmerman GM. Using self- care strategies to make lifestyle changes. Journal of Holistic Nursing 1999;17:169–83.

34. May KM, Evans GG. Health education for homeless populations. Journal of Community Health Nursing 1994;11:229–37.

35. Rothman AJ. Toward a theory- based analysis of behavioral maintenance. Health Psychology 2000;19(1, Suppl):64–9.

36. Fjeldsoe B, Neuhaus M, Winkler E, et al. Systematic review of maintenance of behavior change following physical activity and dietary interventions. Health Psychology 2011;30:99–109.

37. Ryan RM, Patrick H, Deci EL, et al. Facilitating health behaviour change and its maintenance: interventions based on self- determination theory. European Health Psychologist 2008;10:2–5.

38. Brannon L, Feist J. Health psychology. 7th edn. United States of America: Wadsworth: Cengage Learning, 2010: 310–38.

39. Deeks A, Lombard C, Michelmore J, et al. The effects of gender and age on health related behaviors. BMC Public Health 2009;9.

40. Hassed C, de Lisle S, Sullivan G, et al. Enhancing the health of medical students: outcomes of an integrated mindfulness and lifestyle program. Advances in Health Sciences Education 2009;14:387–98.

41. OECD. Health care utilisation OECD Health Statistics (Database); 2016.

42. van Doorslaer E, Wagstaff A, van der Burg H, et al. Equity in the delivery of health care in Europe and the US. Journal of Health Economics 2000;19:553–83.

43. Kaufman J, Synnot A, Ryan R, et al. Face to face interventions for informing or educating parents about early childhood vaccination. The Cochrane Library 2013;46.

44. Kiropoulos LA, Klein B, Austin DW, et al. Is Internet- based CBT for panic disorder and agoraphobia as effective as face- to- face CBT? Journal of Anxiety Disorders 2008;22:1273–84.

45. Frohlich N, Oppenheimer J. Some consequences of e- mail vs. face- to- face communication in experiment. Journal of Economic Behavior & Organization 1998;35:389–403.

46. Squires JE, Sullivan K, Eccles MP, et al. Are multifaceted interventions more effective than single- component interventions in changing health- care professionals' behaviours? An overview of systematic reviews. Implementation Science 2014;9.

47. Dunn AL, Marcus BH, Kampert JB, et al. Comparison of lifestyle and structured interventions to increase physical activity and cardiorespiratory fitness: a randomized trial. JAMA 1999;281:327–34.

48. Singhal N, Misra A, Shah P, et al. Effects of controlled school- based multi- component model of nutrition and lifestyle interventions on behavior modification, anthropometry and metabolic risk profile of urban Asian Indian adolescents in North India. Eur J Clin Nutr 2010;64:364–73.

49. Kreuter MW, Lukwago SN, Bucholtz RDDC, et al. Achieving cultural appropriateness in health promotion programs: targeted and tailored approaches. Health Educ Behav 2003;30:133–46.

50. World Health Organisation. Self- care in the context of primary health care, 2009. Available: http:// apps. searo. who. int/ PDS_ DOCS/ B4301. pdf [Accessed 29 Oct 2018].

on August 13, 2020 by guest. P

rotected by copyright.http://gh.bm

j.com/

BM

J Glob H

ealth: first published as 10.1136/bmjgh-2019-001415 on 6 N

ovember 2019. D

ownloaded from